Free online training program outlines ways to address smoking during cancer care

December 10, 2020
illustration of a cigarette with the ash shaped like people and the person at the end is falling
New online training modules offer a variety of resources for health care providers to more effectively help cancer patients quit smoking and improve treatment outcomes.

Quitting smoking is one of the most effective things cancer patients can do to improve their treatment outcomes, but research shows that less than half of cancer patients who smoke receive assistance to quit.

To help bridge this gap, the Centre for Addiction and Mental Health and the Canadian Partnership Against Cancer teamed up with Graham Warren, M.D., Ph.D., a researcher in MUSC Hollings Cancer Center’s Cancer Control Program, to create free online training modules designed to educate a variety of audiences on the effects of smoking on cancer care. The partnership had Warren engaging medical institutions in all of Canada’s 13 provinces to brainstorm the best way to reach and support this patient population, some of whom live in remote areas.

“Whenever we engaged across these different places, it wasn’t going in to say, ‘This is how it needs to happen.’ It was listening to their needs and resources, and then within those needs and resources trying to address the common theme of how to address tobacco use,” said Warren, the Mary M. Gilbreth Endowed Chair of Clinical Oncology and vice chairman for research in radiation oncology at Hollings. “Each institution has its strengths and weaknesses, and that approach of developing a solution that would work in their case has been key.”

While each institution had a unique set of needs, the group recognized that maintaining a strong, consistent and coherent message across the board was important for creating a national cessation strategy. That’s where the new training modules came into play.

The self-paced program is available to anyone who is interested in learning about tobacco assessment in a cancer care setting but was primarily designed to offer tools to health care providers to support patients through their cancer journeys.

The program’s four modules focus on:

  • The implications of tobacco use on cancer care.
  • Ways to screen for and assess tobacco use.
  • Approaches for treating tobacco use.
  • Ways to adapt smoking cessation for specific patient populations.

Evidence-based components include motivational interviewing, psychosocial approaches and medical interventions. Learners can choose to complete the entire program or only the modules that fit their needs and interests.

According to Warren, who helped to develop tobacco assessment and cessation efforts at Hollings, the program offers tools to help providers across all disciplines, including physicians, nurses, social workers and others.

“It’s designed so that people from different specialty areas can go in and have common training in the problem of smoking, how it can be addressed and where their role might fit into that process,” said Warren.

“Our goal as providers is to achieve the optimal patient outcome and to support patients in their journey through cancer treatments, and smoking is something that impedes that optimal treatment. We want to try to help them transition to a better treatment strategy.”

The need for change

While most people are aware that smoking increases the risk of developing cancer, many fail to realize that quitting smoking is one of the most beneficial things they can do to improve their health, even after a cancer diagnosis.

Warren, along with K. Michael Cummings, Ph.D., and Anthony Alberg, Ph.D., current and former researchers at Hollings, respectively, contributed to the 2014 Surgeon General’s Report, demonstrating that smoking decreases the effectiveness of cancer treatments. Cancer patients who smoke could experience more complications from surgery, reduced efficacy of chemotherapy and radiotherapy, increased risks of developing a second primary tumor and an increase in side effects from treatment. They are also at higher risk of the cancer returning after successful treatment and of dying from other diseases caused by smoking, such as heart disease, chronic obstructive pulmonary disease (COPD) and vascular disease.

Dr. Graham Warren at his desk 
Dr. Graham Warren collaborated with the Centre for Addiction and Mental Health and the Canadian Partnership Against Cancer to develop new smoking cessation training modules. Photo by Sarah Pack

The researchers also contributed to the 2020 Surgeon General’s Report, which demonstrated that quitting smoking after a cancer diagnosis was associated with improved survival.

“Smoking affects patients at all stages of disease, even patients with metastatic cancer,” said Warren. “Improving survival is an excellent outcome from quitting smoking, but even if you don’t cure the cancer, keeping a person out of the hospital by preventing complications from his or her treatment can generate a huge improvement in quality of life.”

Smoking cessation in general also reduces the risk of premature death and can add as much as a decade to life expectancy. In addition to lowering a person’s risk of developing 12 types of cancers, cessation can improve outcomes for patients with heart disease and improve lung function in people with COPD.

While the benefits may seem obvious, ensuring this evidence is communicated effectively to those who may be unaware of the implications of smoking can be a challenge. Health care providers can provide critical points of access in terms of offering smoking cessation counseling and referrals to programs where patients can receive personalized approaches to quitting.

One approach Warren has found to be effective is looking for windows of opportunity when a tobacco user might be more open to change, such as a hospitalization or serious medical diagnosis.

“I think some providers find it difficult to approach cancer patients about smoking, but I don’t think it’s as hard as it used to be. Now we have solid data that shows smoking is bad for cancer treatment, so oncologists can approach patients with better evidence, and I think we’ve disseminated this message much better over the past several years,” said Warren.

Paving a path forward

At Hollings, all hospital patients are automatically referred to smoking cessation programs unless they specifically ask not to be, and cessation programming is also integrated into outpatient care. The Tobacco Treatment Program, led by Cummings and Benjamin Toll, Ph.D., has dedicated cessation counselors and offers a variety of delivery methods for cessation programming, including in person, by phone, via telehealth and through interactive voice recorders and educational materials.

“We have put together an outstanding package for cessation here at MUSC and at Hollings. This is one of the best things we can do to improve outcomes for our cancer patients but also for patients with heart disease, stroke and other types of conditions,” said Warren, who credited Cummings with building and maintaining the cessation program.

Smoking cessation is more important than ever, as the COVID-19 pandemic has left many people feeling anxious and spending more time at home, though Warren admits it will take time to know exactly how the pandemic has affected people’s smoking behaviors. Currently, he’s studying how the pandemic has affected the delivery of smoking cessation support across different territories in Canada, where there’s a national strategy to treat tobacco use specifically as a part of cancer care.

“I look at smoking as a medical issue we need to treat to improve cancer care. Cessation after a cancer diagnosis is one of the best things patients and providers can do to make cancer treatment more effective.”
— Dr. Graham Warren

“When COVID hit, within a couple of weeks, we had cessation programs that were shut down, people reallocated to other clinical activities or funding that was stopped,” said Warren. “We were able to maintain our programming at MUSC, but COVID has really hit cessation hard nationally because people didn’t look at it as a necessary component of health care or cancer care.”

In addition to current programming, researchers at Hollings are constantly searching for new and innovative ways to encourage smoking cessation. Recent projects include using technology to make smoking cessation clinical trials available remotely, improving cessation by incentivizing cancer patients preparing for treatment, and exploring whether lowering nicotine content in cigarettes to make them less addictive changes smoking behaviors.

Outside of MUSC, Warren has helped over 40 programs and institutions across the U.S. and Canada tackle smoking cessation by determining the best ways to approach tobacco use based on each organization’s needs and resources. Researchers at Hollings have also worked with the National Cancer Institute to help to roll out the development of tobacco treatment programs at 42 NCI-designated cancer centers and have worked with the Canadian Partnership Against Cancer to develop national priorities, guidelines and cessation approaches for cancer patients across Canada.

“The work by the Centre for Addiction and Mental Health has brought together thoughtful training modules to help providers tackle this issue,” Warren said. He hopes the modules will help providers to feel more comfortable opening a dialogue with their patients about tobacco use, especially in cancer care.

“I look at smoking as a medical issue we need to treat to improve cancer care,” said Warren. “Cessation after a cancer diagnosis is one of the best things patients and providers can do to make cancer treatment more effective.”

Click here for more information or to enroll in the online training modules.